Statement Of Fitness For Work - Progress Certificate Form - Nt Worksafe
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1
2Form
Statement of fitness for work
– Progress certificate
Medical practitioner to retain a copy
Recommended for a maximum 28 days duration
This statement to be given to worker
Note: maximum referral period for rehabilitation treatment prior
to review is initially 14 days, and then 28 days subsequent
referrals to the same discipline.
1.
Worker details
Surname:
Given names:
Date of birth:
/ /
Date of injury or disease:
/ /
Address:
Suburb:
State:
Postcode:
Home number:
Work number:
Mobile number:
Email address:
2.
Employer details
Employer name:
Address:
Suburb:
State:
Postcode:
3.
Medical assessment
Date of examination:
/ /
Time of examination:
AM
PM
Clinical findings / diagnosis at this examination:
4.
Fitness for work
(tick only those boxes which apply)
In my opinion that as from the date of this statement, the worker is:
Fit to return to pre-injury duties, no further treatment required.
Fit to return to pre-injury duties, but requires further treatment
Fit to return to work for restricted hours / days from:
/ /
to
/ /
(inclusive)
hours per day
hours per week
Fit to return to work on restricted duties from:
/ /
to
/ /
(inclusive)
Restricted duties:
Avoid prolonged standing / walking / sitting
Avoid squatting / kneeling / ladders / steps
No lifting anything heavier than:
5kg
10kg
15kg
20kg
Avoid repetitive use of affected body part
Avoid repetitive bending / lifting
Other
(please specify)
Totally unfit for work from:
/ /
to
/ /
(inclusive)
I will review the worker (date of next appointment):
/ /
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